Pennsylvania State Hospital Risk Management Summary and Indicator Report

June 2019

Prepared by: Christina Sterner, M.S. CPIE

Wernersville State Hospital E-Mail: csterner@pa.gov

Contributors: SMH CPIEs & PI Staff

Valerie Minnich, RPh August 23, 2019

Office of Mental Health and Substance Abuse Services Ӏ Bureau of Community & Hospital Operations

P.O. Box 2675 Ӏ Harrisburg, Pennsylvania 17105 Ӏ Phone: 717.772.7160 Ӏ Fax: 717.787.2866

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Introduction The State Hospital Risk Management System defines an incident as any patient-related event that has the potential for, or which results in, a negative impact upon the quality of patient care or services, including injury or death of a person served in the state hospital system. Past reports can be found on the DHS website using the following link. http://www.dhs.pa.gov/publications/forproviders/statehospitalriskmanagementsummaryreports/

The data dictionary for the measurement system was updated on October 1, 2008, and is available for review as attachments to OMHSAS Bulletin titled Management of Incidents: SI-815 Incident Reporting and Risk Management Policy and Procedural Change. (Available via bulletin search at http://www.dhs.pa.gov/ .)

Table of Contents Indicator/Measure Table Page Risk Management Indicators Census and Rates of Incidents 1 3 Thirteen-Month Trend of Incidents 3 Six-Month Summary of Selected Events 4 Category or Cause of Incidents: Civil 2 5 Primary Effect of Incidents: Civil 3 6 Category or Cause of Incidents: Forensic 4 7 Effect of Incidents: Forensic 5 7 Cause of Incidents: Long Term Care 6 8 Effect of Incidents: Long Term Care 7 8 Cause of Incidents: SRTP 8 9 Effect of Incidents: SRTP 9 9 13-Month Rate of Type 1 Falls per 1,000 Days of Care 10 10 13-Month Trend of Type 1 Falls 10 Hours of Seclusion Use 11 11 Number of Seclusion Events 12 11 Total Hours of Mechanical Restraint by Unit 13 11 Hours of Mechanical Restraint Use: 12 Months 14 11 Number of Mechanical Restraint Events: 12 Months 15 11 Hours of Physical Restraint Use by Unit 16 12 Hours of Physical Restraint Use: 12 Months 17 12 Number of Physical Restraint Events: 12 Months 18 12 24-Month Trend of Restraint and Seclusion Hours 13 Patient-to-Patient Assaults by Unit 19 14 13-Month Rate of Patient-to-Patient Assault Events with Injury per 1,000 Days-of-Care 20 14 Patient-to-Staff Assaults by Unit 21 15 13-Month Rate of Patient-to-Staff Assaults with Injury to Staff per 1,000 Days-of-Care 22 15 Risk Adjusted Table of Selected Safety Indicators 23 16

Wellness Indicators Tobacco Users 24 17 Reasons for Hospitalization as a Result of an Incident 25 17 Medication Use Indicators

Benzodiazepines 26 18 Multiple Atypicals 27 18 Typical-Atypical 28 18 STAT Medication Usage

Civil 29 19 Forensic 30 20 ACT 21 (SRTP) 31 20

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During June 2019, a total of 1177 incident reports were completed by the state hospital system. Additional records addressing specific categories from the previous month were included on page 4 of this report. The following is a breakdown of incidents by individual facility and type of care:

Table 1 - Number of Incident Reports

Thirteen-Month Trend of Incidents by Type of Care per 1,000 Days of Care

Census 6/30/2019 Days Provided Incidents Per 1000 Days-of-CareClarks Summit 153 4602 59 12.8

Danville 158 4730 199 42.1Norristown 107 3208 94 29.3

Torrance 152 4366 137 31.4Warren 138 4200 167 39.8

Wernersville 257 7732 215 27.8Total Civil 965 28838 871 30.2

ForensicNorristown 241 7219 182 25.2

Torrance 98 2929 34 11.6Total Forensic 339 10148 216 21.3

Act 21 Act 21 60 1685 11 6.5

Total Act 21 60 1685 11 6.5Long Term Care

South Mountain 137 4073 79 19.4Total L. T. C. 137 4073 79 19.4

Total 1501 44744 1177 26.3

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

Inci

dent

Rat

e Pe

r 1K

Day

s-of

-Car

e

Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19Civil 27.6 31.2 30.3 35.7 30.8 31.0 28.8 29.5 29.1 28.8 30.5 32.1 30.2

Forensic 20.6 18.2 16.3 16.9 18.1 15.4 18.5 19.7 18.6 18.8 17.4 21.7 21.3

Long Term Care 6.9 2.1 11.0 15.3 13.3 6.4 16.0 12.9 24.4 21.4 20.1 16.9 19.4

Act 21 4.4 7.4 3.2 6.2 10.2 8.6 11.2 12.9 11.0 2.9 9.9 11.2 6.5

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*Note: Rules regarding the reporting of incidents involving patient-to-patient assaults require a separate incident report form on each person involved in an altercation. This includes both the aggressor, when known and any other person involved. The numbers reported above reflect the monthly, total number of SI-815 reports coded as Patient-to-Patient Assaults and not the actual number of altercations. The following table is refreshed each month from the most recent data (recent 6 month period) available from the State Hospital System RM database.

CATEGORY Count Jan_19 Feb_19 Mar_19 Apr_19 May_19 Jun_19Accident-Injury 251 28 42 48 57 46 30Adverse Drug Reaction 8 1 6 1Aggression 1041 148 174 161 189 182 187Airway Obstruction type 1 Intervention 20 5 3 2 4 3 3Airway Obstruction type 2 No Intervention 10 2 1 1 3 3Alleged Nonconsensual Sexual Activity 11 2 4 3 2Alleged Pt. Abuse 83 16 16 13 13 13 12Alleged Suspected Criminal Act 2 1 1Assault, Pt./Pt 1771 297 252 275 277 384 286Assault, Pt./Staff 426 85 62 53 74 80 72Assault: Patient/Other 3 1 1 1AWOL/UA 45 9 7 7 6 8 8AWOL-Attempt 35 5 4 8 6 6 6AWOL-Late 38 1 3 2 4 18 10Change in Medical Status-Stabilized 47 17 8 4 3 5 10Change in Medical Status-Transferred 322 56 34 57 50 67 58Charged post admit/crime committed prior to admit 5 1 1 1 2Charged with alleged crime off hospital grounds 5 5Communications Sys. Misuse 42 4 10 7 9 5 7Community Incident 9 2 1 2 2 1 1Contraband Possession 131 22 21 19 21 20 28Fall Type 1-Injury with treatment 289 50 38 53 56 42 50Fall Type 2-No treatment needed 724 107 119 133 129 111 125Family Concern 10 2 3 1 2 2Fire Setting 1 1Illicit Substance Use/Possession 4 2 1 1Indeterminate/Unconfirmed Cause of Injury 95 11 7 20 19 19 19Medication Error 113 26 21 17 22 14 13Missing Property 27 5 4 2 5 6 5Other 403 56 64 60 82 71 70Procedural Treatment Error 21 1 6 5 5 4Property Damage 93 13 15 9 11 26 19Seizure 53 7 9 18 7 4 8Self-Injurious behavior 724 123 104 125 97 135 140Sexual Behavior 57 3 3 23 9 9 10Smoking Violation 56 3 11 17 8 3 14Substantiated Nonconsensual Sexual Activity 2 2Substantiated Patient Abuse 2 1 1Suicide Attempt 9 2 3 3 1Suicide threat/plan 19 3 6 3 4 3Theft 8 3 2 1 1 1Unknown 1 1Unsubstantiated Nonconsensual Sexual Activity 6 2 1 3Unsubstantiated Patient Abuse 21 16 1 2 1 1

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Table 2 - Category or Cause of Incidents in the Civil Hospitals

Primary Cat # CLA DAN NOR TOR WAR WER CountAccident-Injury 1 1 1 2 4 1 10Aggression 9 17 5 39 37 28 135Airway Obstruction type 1 Intervention 2 0 0 0 0 0 2Airway Obstruction type 2 No Intervention 0 1 0 0 2 0 3Alleged Pt. Abuse 0 0 2 0 0 8 10Assault, Pt./Pt 2 56 31 11 26 28 154Assault, Pt./Staff 4 22 3 3 11 8 51AWOL/UA 1 1 1 0 3 1 7AWOL-Attempt 0 2 1 0 1 2 6AWOL-Late 0 0 0 0 10 0 10Change in Medical Status-Stabilized 1 0 2 0 5 1 9Change in Medical Status-Transferred 5 6 2 8 6 11 38Communications Sys. Misuse 3 0 0 1 3 0 7Community Incident 1 0 0 0 0 0 1Contraband Possession 0 3 0 2 15 4 24Fall Type 1-Injury with treatment 10 2 7 9 5 6 39Fall Type 2-No treatment needed 15 15 13 12 15 33 103Family Concern 0 0 0 0 1 0 1Illicit Substance Use/Possession 0 0 0 1 0 0 1Indeterminate/Unconfirmed Cause of Injury 1 0 3 7 0 5 16Medication Error 0 5 0 2 0 0 7Missing Property 0 1 0 1 0 2 4Other 0 10 5 10 3 36 64Property Damage 0 5 4 0 0 1 10Seizure 0 0 0 0 0 7 7Self-Injurious behavior 4 50 13 23 6 28 124Sexual Behavior 0 2 0 2 2 2 8Smoking Violation 0 0 0 2 9 2 13Suicide threat/plan 0 0 0 0 1 1 2Theft 0 0 1 0 0 0 1

Unsubstantiated Nonconsensual Sexual Activity 0 0 0 1 2 0 3

Unsubstantiated Patient Abuse 0 0 0 1 0 0 1Totals 59 199 94 137 167 215 871

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Table 3 - Primary Effect of Incidents in the Civil Hospitals

Primary effect CLA DAN NOR TOR WAR WER CountUnknown 0 0 0 0 0 1 1Abrasion/scrape/scratch/hematoma 9 17 16 16 11 21 90Allergic reaction 0 0 0 1 0 0 1Bite-Human 0 0 0 0 0 1 1Body System Illness 6 5 1 0 5 5 22Bruise/contusion/discoloration 2 3 2 8 2 5 22Dislocation 0 0 0 0 0 1 1Edema/swelling 0 1 1 1 3 1 7Emesis 0 0 0 1 0 0 1Epistaxis 0 0 1 1 1 0 3Erythema/redness 0 5 1 2 2 4 14Fever 0 0 0 2 0 0 2Fracture 0 0 1 0 0 0 1Ingestion of foreign body 0 7 1 2 0 17 27Laceration: NO sutures/staples/steri-strips 3 3 2 0 0 1 9Laceration: with steristrips/glue 0 1 0 1 0 1 3Laceration: with sutures/staples 1 0 0 0 0 0 1Lethargy 0 0 0 1 0 0 1Muscle pull/strain/sprain 0 1 0 0 0 0 1No Injury/NA 36 149 59 89 138 136 607Other 0 3 4 8 0 1 16Pain unspecified 0 2 0 0 1 2 5Pain, Specified 0 2 4 2 3 11 22Respiratory Distress 0 0 1 0 0 1 2Seizure 0 0 0 0 0 5 5Syncopal episode 0 0 0 1 0 1 2Unconscious/Unresponsive 2 0 0 1 1 0 4Totals 59 199 94 137 167 215 871

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Table 4 - Cause of Incidents in the Forensic Units Category or Cause of Incidents in the Forensic Service by Unit

Sys

Primary Cat # 51A1 51A2 51B1 51B2 51C1 51C2 10D1 10E1 Total FB3 FB4 FC1 FC2 Total CountAccident-Injury 1 1 1 1 2Aggression 3 2 1 6 1 1 5 6 25 6 7 1 14 39Airway Obstruction type 1 Intervention 0 1 1 1Alleged Pt. Abuse 1 1 0 1Assault, Pt./Pt 4 52 4 6 16 12 12 106 0 106Assault, Pt./Staff 12 2 1 1 1 17 3 3 20AWOL/UA 1 1 0 1Change in Medical Status-Stabilized 0 1 1 1Change in Medical Status-Transferred 1 4 5 3 3 8Fall Type 1-Injury with treatment 2 2 3 3 5Fall Type 2-No treatment needed 1 1 3 5 2 1 3 8Family Concern 0 1 1 1Indeterminate/Unconfirmed Cause of Injury 0 1 2 3 3Medication Error 1 1 0 1Other 1 1 1 1 2Property Damage 1 1 1 1 4 0 4Seizure 1 1 0 1Self-Injurious behavior 6 2 1 1 10 0 10Sexual Behavior 1 1 2 0 2Totals 8 73 7 17 18 18 20 21 182 18 1 13 2 34 216

NSH TSH

Table 5 - Effect of Incidents in the Forensic Service by Unit

SysEFFECT 51A1 51A2 51B1 51C1 51C2 51B2 10D1 10E1 Total FB3 FB4 FC1 FC2 Total Count

Abrasion/scrape/scratch/hematoma 1 2 2 3 1 1 1 1 12 3 3 15Bite-Human 0 1 1 1Body System Illness 1 1 2 0 2Bruise/contusion/discoloration 2 1 1 4 1 1 5Cellulitis 0 1 1 1Dislocation 0 1 1 1Edema/swelling 2 1 1 1 5 1 1 6Epistaxis 1 2 3 0 3Erythema/redness 2 1 1 1 5 0 5Ingestion of foreign body 1 1 0 1Laceration: NO sutures/staples/steri-strips 1 1 2 4 0 4Laceration: with sutures/staples 0 1 1 1Lethargy 0 1 1 1No Injury/NA 7 56 3 13 12 13 11 15 130 12 1 7 1 21 151Other 1 1 1 3 1 1 4Pain unspecified 1 1 1 1 2Pain, Specified 6 1 1 1 1 10 0 10Seizure 1 1 0 1Unconscious/Unresponsive 1 1 1 1 2Totals 8 73 7 18 18 17 20 21 182 18 1 13 2 34 216

NSH TSH

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Table 6 -Cause of Incidents in the Long Term Care Facility

Cause 3A 3B 5A 6A 6B CountAccident-Injury 1 6 1 4 5 17Aggression 2 2 4Assault, Pt./Pt 3 3 2 8Assault, Pt./Staff 1 1Change in Medical Status-Transferred 4 3 5 12Contraband Possession 2 1 3Fall Type 1-Injury with treatment 2 3 1 6Fall Type 2-No treatment needed 1 7 3 2 13Medication Error 1 1 3 5Missing Property 1 1Procedural Treatment Error 1 3 4Property Damage 1 1 2 4Smoking Violation 1 1Totals 10 13 23 10 23 79

Table 7 - Effect of Incidents in the Long Term Care Facility

EFFECT 3A 3B 5A 6A 6B CountAbrasion/scrape/scratch/hematoma 3 4 1 1 4 13Blister 1 1Bruise/contusion/discoloration 2 1 4 2 9Edema/swelling 1 1Erythema/redness 2 2Lethargy 1 2 5 8No Injury/NA 3 7 16 5 11 42Other 1 1Respiratory Distress 2 2Totals 10 13 23 10 23 79

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Act-21-Sexual Responsibility & Treatment Program at Torrance State Hospital

In July 2003, the Pennsylvania Legislature enacted Act 21 for adjudicated youth, aging out of the juvenile justice system who have a "mental abnormality" that renders them unable to control their violent sexual impulses. The Act mandates the state to provide mental health and sex-offense specific treatment to an identified population that had been adjudicated of certain sex crimes, received treatment in a juvenile program, yet remains a significant risk to sexually re-offend after reaching the age of 21, an age when oversight by the juvenile justice system typically ends. The Act requires the referral of such individuals who have committed these specific crimes to the Pennsylvania Sexual Offenders Assessment Board (SOAB) ninety days prior to their 20th birthday for purposes of determining if the individual has "serious difficulty in controlling sexually violent behavior." If so determined, a petition for a mental health hearing will be made for determination of civil commitment to the Sexual Responsibility and Treatment Program (SRTP) on the grounds of Torrance State Hospital. On July 1, 2006, the operation of this program transferred from an independent contractor to the Torrance State Hospital.

Table 8 - Cause of Incidents in the Sexual Responsibility and Treatment Program

Cause TOR CountAggression 5 5Fall Type 2-No treatment needed 1 1Other 1 1Self-Injurious behavior 4 4Totals 11 11

Table 9 - Effect of Incidents in the Sexual Responsibility and Treatment Program

Primary effect TOR CountAbrasion/scrape/scratch/hematoma 4 4Bruise/contusion/discoloration 1 1No Injury/NA 5 5Other 1 1Totals 11 11

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Falls

Falls within the state hospital risk management system are divided into two categories, type 1 and type 2, with the need for medical intervention or lack thereof defining the difference. The following data relates to falls, type 1 which are defined as an involuntary descent to a lower position, excluding seizures, that is witnessed or reported and requires medical intervention.

Table 10 - 13-Month Rate of Type 1 Falls Per 1,000 Days-of-Care

13-Month Trend of Type 1 Falls by Type of Care per 1,000 Days-of-Care

A21 LTCM/Year Cla Dan Nor Tor War Wer Ttl Nor Tor Total A21 SMRC

Jun-18 1.15 0.84 1.31 0.65 1.42 2.25 1.36 0.92 0.00 0.60 0.00 0.71 1.10Jul-18 0.37 1.22 1.27 0.84 0.69 1.29 0.96 1.59 0.00 1.04 0.00 0.23 0.87

Aug-18 1.11 0.61 2.21 2.06 1.14 1.56 1.41 1.41 0.33 1.04 0.00 1.17 1.26Sep-18 1.55 0.64 1.62 3.30 0.94 2.17 1.75 0.55 0.34 0.48 0.00 1.46 1.41Oct-18 1.14 1.84 0.00 3.02 0.93 2.36 1.71 0.54 1.32 0.81 0.00 2.13 1.51

Nov-18 1.39 0.42 1.31 2.02 1.46 1.09 1.25 0.55 0.00 0.35 0.00 0.99 1.00Dec-18 1.15 0.41 1.59 1.92 0.46 1.31 1.14 0.72 0.00 0.47 0.59 2.38 1.10Jan-19 1.58 0.82 2.53 1.50 1.13 1.18 1.38 1.05 0.33 0.80 0.00 0.48 1.12Feb-19 1.35 0.00 1.76 2.19 0.46 0.73 1.00 0.92 0.00 0.62 0.65 1.33 0.94Mar-19 1.85 1.22 1.60 1.13 0.66 1.30 1.29 1.22 0.34 0.95 0.00 1.14 1.15Apr-19 1.95 0.42 1.31 2.31 1.39 1.06 1.36 0.58 1.36 0.81 1.24 0.98 1.20

May-19 1.67 0.20 0.92 0.67 0.91 0.88 0.87 0.68 0.66 0.68 0.00 1.67 0.87Jun-19 2.17 0.42 2.18 2.06 1.19 0.78 1.35 0.28 1.02 0.49 0.00 1.47 1.12

Civil Hospital Forensic Sys Avg

J-18 J-18 A-18 S-18 O-18 N-18 D-18 J-19 F-19 M-19 A-19 M-19 J-19Civil 1.36 0.96 1.41 1.75 1.71 1.25 1.14 1.38 1.00 1.29 1.36 0.87 1.35

Forensic 0.60 1.04 1.04 0.48 0.81 0.35 0.47 0.80 0.62 0.95 0.81 0.68 0.49

LTC 0.71 0.23 1.17 1.46 2.13 0.99 2.38 0.48 1.33 1.14 0.98 1.67 1.47

Act-21 0.00 0.00 0.00 0.00 0.00 0.00 0.59 0.00 0.65 0.00 1.24 0.00 0.00

0.00

0.50

1.00

1.50

2.00

2.50

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State Hospital Use of Seclusion

Civil and Forensic Data on seclusion use for psychiatric reasons includes the civil and forensic populations and is reported for both monthly and yearly totals.

Table 11 - Hours of Seclusion Use, Monthly Totals for Past Year

No Use of Seclusion in PA State Hospital system since July 2013

Table 12 - Number of Seclusion Events, Monthly Totals for Past Year

No Use of Seclusion in PA State Hospital system since July 2013

State Hospital Use of Mechanical Restraint

Civil and Forensic Data on mechanical restraint use for psychiatric reasons includes the forensic and civil populations and is reported for both monthly and yearly totals.

Table 13 - Total Hours of Mechanical Restraint Use by Hospital and Unit In Month

No use of Mechanical Restraint in PA State Hospital system since September 2015

Table 14 - Hours of Mechanical Restraint Use, Monthly Totals for Past Year

No use of Mechanical Restraint in PA State Hospital system since September 2015

Table 15 - Number of Mechanical Restraint Events, Monthly Totals for Past Year

No use of Mechanical Restraint in PA State Hospital system since September 2015

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State Hospital Use of Physical Holds

Data on physical holds use for psychiatric reasons includes all level of care populations and is reported for both monthly and yearly totals. Physical hold events lasting less than 60 seconds are reflected as 0.00 hours.

Table 16 - Hours of Physical Holds (Restraint) Used by Hospital & Unit

ABV WARD Total ABV WARD Total ABV WARD TotalNOR 51A2 0.40 NOR 10D2 0.07 NOR 51A1 0.01TOR FC1 0.37 NOR 10E2 0.05 NOR 01C2 0.01TOR 011 0.33 TOR 064 0.05 WER 35-4 0.01TOR FB3 0.27 CLA 3 0.05 CLA 7 0.01TOR 063 0.25 NOR 01C1 0.04 NOR 51B1 0.01NOR 51B2 0.20 NOR 51C2 0.04 DAN 311 0.004DAN 312 0.15 CLA 2 0.03 NOR 01A2 0.003TOR 024 0.10 DAN 212 0.03 DAN 211 0.003NOR 51C1 0.09 DAN 210 0.03 NOR 10E1 0.001TOR FC2 0.08 NOR 10D1 0.02

Table 17 - Hours of Physical Holds (Restraint) Use, Monthly Totals for Past Year

ABV Total Jul_18 Aug_18 Sep_18 Oct_18 Nov_18 Dec_18 Jan_19 Feb_19 Mar_19 Apr_19 May_19 Jun_19CLA 6.81 0.73 0.69 0.75 0.67 0.38 0.21 0.88 1.27 0.51 0.46 0.13 0.14DAN 4.22 0.25 0.43 0.14 0.05 0.25 0.17 0.82 0.93 0.39 0.08 0.18 0.53NOR 8.55 1.03 1.07 0.52 0.24 0.51 0.52 0.39 0.18 0.54 1.36 1.23 0.95TOR 12.42 1.15 1.40 2.52 0.10 0.77 0.78 0.43 1.28 0.90 0.92 0.72 1.45WAR 0.38 0.03 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.35 0.00WER 3.09 0.50 0.10 0.02 0.13 0.05 0.30 0.45 0.30 0.18 0.27 0.78 0.01Total 35.48 3.70 3.70 3.96 1.19 1.96 1.99 2.96 3.96 2.51 3.08 3.39 3.08

Table 18 - Number of Physical Holds (Restraint) Events, Monthly Totals for Past Year

ABV Total Jul_18 Aug_18 Sep_18 Oct_18 Nov_18 Dec_18 Jan_19 Feb_19 Mar_19 Apr_19 May_19 Jun_19CLA 104 7 14 7 11 12 4 9 17 6 9 5 3DAN 120 4 10 7 3 13 18 21 16 10 3 5 10NOR 387 27 29 34 23 29 38 26 14 35 42 43 47TOR 104 8 6 8 2 11 8 6 13 7 7 8 20WAR 2 1 0 0 0 0 0 0 0 0 0 1 0WER 76 14 4 3 9 3 8 7 7 5 5 10 1Total 793 61 63 59 48 68 76 69 67 63 66 72 81

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J-18 J-18 A-18 S-18 O-18 N-18 D-18 J-19 F-19 M-19 A-19 M-19 J-19

Mechanical Restraint 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Physical Restraint 2.24 2.36 2.55 2.36 0.85 1.39 1.87 1.87 3.63 2.41 2.6 3.31 1.17

0

1

1

2

2

3

3

4

4

Tota

l Hou

rs b

y M

onth

Mechanical Restraint Physical Restraint Linear (Mechanical Restraint) Linear (Physical Restraint)

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Assaults

Assaults within the state hospital system are defined as any aggressive act by a patient, involving physical contact that may or may not result in injury. Assaults can be directed at a peer, staff or any other individual. The system was designed to require an incident report (form SI-815) on any patient involved in a physical altercation regardless of who may have started the assault. Therefore, every patient-to-patient altercation will result in at least two incident reports.

Table 19 - Patient-to-Patient Assaults by Unit, All Levels of Care

ABV WARD Cnt ABV WARD Cnt ABV WARD CntNOR 51A2 52 NOR 10E2 6 SMO 3B 3DAN 212 26 DAN 310 6 SMO 5A 3NOR 51C1 16 WAR 3NM 6 TOR 012 2DAN 211 16 NOR 51B2 6 WAR 2NM 2NOR 01C2 15 WER 35-3 5 NOR 01A2 2WER 35-2 13 WAR 3IM 5 CLA 2 2NOR 10D1 12 NOR 51B1 4 SMO 6A 2NOR 10D2 12 TOR 014 4 WER 37-1 2NOR 51C2 12 TOR 013 4 WAR 3IF 2NOR 01C1 10 NOR 01A1 4 TOR 022 1WAR 3SW 8 NOR 51A1 4 DAN 210 1WER 35-4 7 WAR 2SW 3 WER 34-4 1DAN 312 7

Table 20 - Rate of Patient-to-Patient Assaults Events with Patient Injury per 1,000 Days-of-Care

Civil Forensic SRTP

Pt.-to-Pt. Assault w/ any Injury Cla Dan Nor Tor War Wer Tot. Nor Tor Tot. SRTP

Jun-18 0.19 1.47 2.94 1.08 0.94 1.33 1.22 3.31 0.69 2.40 0.00

Jul-18 0.74 0.20 3.82 1.05 0.69 0.90 1.05 3.53 0.34 2.44 0.00

Aug-18 0.19 0.61 0.95 0.83 2.05 1.69 1.08 2.12 1.00 1.73 0.00

Sep-18 0.77 1.48 3.88 1.98 1.65 1.36 1.68 2.94 0.34 2.03 0.00

Oct-18 0.57 0.82 2.54 1.51 0.23 0.66 0.94 0.54 0.33 0.46 0.00

Nov-18 0.99 2.10 1.64 2.92 0.97 0.82 1.50 2.01 1.34 1.77 0.00

Dec-18 0.38 1.22 2.54 1.07 0.92 1.70 1.27 2.69 0.00 1.74 0.00

Jan-19 0.79 1.22 1.90 1.29 3.17 0.92 1.44 3.16 1.31 2.51 0.00

Feb-19 0.22 2.07 2.81 2.19 0.70 1.31 1.45 2.95 2.23 2.71 0.00

Mar-19 0.21 0.81 1.28 1.13 1.33 0.65 0.85 4.74 0.00 3.28 0.00

Apr-19 1.08 1.06 2.62 1.85 0.69 1.32 1.36 3.78 1.36 3.06 0.00

May-19 0.21 0.61 3.38 1.12 0.68 1.26 1.11 3.83 0.66 2.90 1.18

Jun-19 0.22 1.27 2.81 0.92 0.71 1.16 1.11 4.43 0.00 3.15 0.00

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Table 21 - Patient-to-Staff Assault Events by Unit, All Levels of Care

ABV WARD Cnt ABV WARD Cnt ABV WARD CntNOR 51A2 12 DAN 210 2 WER 37-3 1DAN 212 8 WER 35-4 2 SMO 5A 1WAR 2SW 5 CLA 3 2 TOR 011 1DAN 311 4 NOR 01C1 2 TOR 022 1WAR 3SW 4 DAN 211 2 TOR 024 1DAN 312 3 CLA 7 1 WAR 2NM 1DAN 310 3 NOR 01A1 1 WAR 3NM 1TOR FB3 3 NOR 10D1 1 WER 35-2 1WER 35-3 3 CLA 2 1 WER 37-1 1NOR 51B2 2 NOR 51C2 1 NOR 51C1 1

Table 22 - Rate of Patient-to-Staff Assault Events with Injury to Staff per 1,000 Days-of-Care

Civil Forensic SRTP

Pt/Staff Assault w/ Staff Inj per 1K days Cla Dan Nor Tor War Wer Tot. Nor Tor Tot. SRTP

Jun-18 0.19 0.84 1.31 0.65 0.71 0.40 0.61 0.55 1.04 0.72 0.00

Jul-18 0.00 0.41 0.64 1.26 1.15 1.16 0.79 0.71 0.00 0.46 0.00

Aug-18 0.56 1.41 1.58 0.62 1.82 1.01 1.12 0.53 0.00 0.35 0.00

Sep-18 0.19 0.21 0.32 0.22 2.36 0.68 0.65 0.55 1.02 0.72 0.00

Oct-18 0.38 0.61 0.32 1.73 0.93 0.66 0.77 0.54 0.33 0.46 0.00

Nov-18 0.40 0.42 0.33 0.00 3.65 0.82 0.90 0.55 0.33 0.47 0.00

Dec-18 0.96 0.61 0.32 0.21 1.38 0.79 0.74 1.25 0.33 0.93 0.59

Jan-19 0.59 1.22 0.32 0.86 0.45 0.00 0.54 0.35 0.33 0.34 0.00

Feb-19 0.67 0.46 0.35 1.22 0.93 0.73 0.74 0.00 0.00 0.00 0.65

Mar-19 0.21 0.00 0.00 0.23 0.00 0.52 0.20 0.46 0.00 0.32 0.65

Apr-19 1.30 0.00 1.31 0.46 0.69 0.53 0.66 0.15 0.34 0.20 0.00

May-19 0.00 0.20 0.31 0.67 0.45 0.51 0.37 0.82 0.00 0.58 0.59

Jun-19 0.43 0.63 0.31 0.23 0.24 0.52 0.42 0.69 0.68 0.69 0.00

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Table 23 - Risk Adjusted Safety Indicators Jun-19 Civil Forensic

Month Cla Dan Nor Tor War Wer C. Total Nor Tor F. Total LTC SRTP SystemPatient Days 4602 4730 3208 4366 4200 7732 28838 7219 2929 10148 4073 1685 44744

Census 153 158 107 152 138 257 965 241 98 339 137 60 1501Safety Indicators

Type 1 Falls (count) 10 2 7 9 5 6 39 2 3 5 6 0 50Num Per 1,000 Pt Days 2.17 0.42 2.18 2.06 1.19 0.78 1.35 0.28 1.02 0.49 1.47 0.00 1.12

Total Falls (count) 25 17 20 21 20 39 142 7 6 13 19 1 175Num Per 1,000 Pt Days 5.43 3.59 6.23 4.81 4.76 5.04 4.92 0.97 2.05 1.28 4.66 0.59 3.91

PT:PT Assaults w/Injury(count) 1 6 9 4 3 9 32 32 0 32 1 0 65Num Per 1,000 Pt Days 0.22 1.27 2.81 0.92 0.71 1.16 1.11 4.43 0.00 3.15 0.25 0.00 1.45

Total PT:PT Assault Events (count) 2 56 31 11 26 28 154 106 0 106 8 0 268Num Per 1,000 Pt Days 0.43 11.84 9.66 2.52 6.19 3.62 5.34 14.68 0.00 10.45 1.96 0.00 5.99

PT:Staff Assaults w/Injury(count) 2 3 1 1 1 4 12 5 2 7 1 0 20Num Per 1,000 Pt Days 0.43 0.63 0.31 0.23 0.24 0.52 0.42 0.69 0.68 0.69 0.25 0.00 0.45

Total PT:Staff Assault Events (count) 4 22 3 3 11 8 51 17 3 20 1 0 72Num Per 1,000 Pt Days 0.87 4.65 0.94 0.69 2.62 1.03 1.77 2.35 1.02 1.97 0.25 0.00 1.61

SIB Events (count) 4 50 13 23 6 28 124 10 0 10 0 4 138Num Per 1,000 Pt Days 0.87 10.57 4.05 5.27 1.43 3.62 4.30 1.39 0.00 0.99 0.00 2.37 3.08

Total Physical Restraint Hours 0.14 0.53 0.05 0.44 0 0.01 1.17 0.77 0.71 1.48 0.3 2.95Num Per 1,000 Pt Days 0.03 0.11 0.02 0.10 0.00 0.00 0.04 0.11 0.24 0.15 0.18 0.07

Medication MeasuresBenzodiazepines 92 75 68 49 75 80 439 13 12 25 8 472

Percentage of Census 0.60 0.47 0.64 0.32 0.54 0.31 0.45 0.05 0.12 0.07 0.13 0.31

Multiple Atypicals 18 38 4 42 47 51 200 16 19 35 0 235Percentage of Census 0.12 0.24 0.04 0.28 0.34 0.20 0.21 0.07 0.19 0.10 0.00 0.16

Typical- Atypical 37 46 48 55 38 124 348 58 41 99 0 447Percentage of Census 0.24 0.29 0.45 0.36 0.28 0.48 0.36 0.24 0.42 0.29 0.00 0.30

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Wellness Indicators The National Association of State Mental Health Program Directors (NASMHPD) issued a report in October 2006 about mortality and morbidity in people with serious mental illness (SMI). According to Mental Health America’s Survey of People with Schizophrenia and Providers (www.mentalhealthamerica.net), the NASMHPD report revealed that people with SMI die on average 25 years earlier than the general population. The major natural causes of death for people with SMI are heart disease, diabetes, respiratory disease and infectious disease. Many of the risk factors for these diseases are modifiable. Beginning June 2008, the state began compiling and comparing data on the number of tobacco users (Table 24) in our state hospitals.

Table 24 - Tobacco Users on Last Day of Month Civil and Long Term Care

Between July 2018 and December 2018 all six State Mental Hospitals became tobacco free campuses.

Table 25 - Reasons for Hospitalizations as the Result of an Incident, All Levels of Care The Risk Management System requires that an incident report form be completed anytime a person is transported from a state hospital to an acute care hospital. This includes if the person was only seen in the emergency room, received diagnostic tests and/or was actually admitted. It does not include hospitalizations for a preplanned procedure, test or surgery.

Cause CLA DAN NOR TOR WAR WER CountAccident-Injury 1 1Airway Obstruction type 1 Intervention 1 1Assault, Pt./Pt 2 1 1 1 5Change in Medical Status-Stabilized 1 1 2Change in Medical Status-Transferred 4 5 7 8 5 9 38Communications Sys. Misuse 1 1Fall Type 1-Injury with treatment 3 3Fall Type 2-No treatment needed 1 1 2Other 4 1 5Self-Injurious behavior 2 4 2 1 4 13Totals 8 13 13 11 10 16 71

Month Tobacco Users CLA DAN NOR TOR WAR WER Civil Total LTC System Total

Jul-18 Total Users 98 45 21 49 83 0 296 11 307

% of Census 56% 28% 21% 31% 58% 0% 30% 8% 21%Nov-18 Total Users 0 0 23 34 53 0 110 10 120

% of Census 0% 0% 23% 22% 39% 0% 11% 7% 8%Mar-19 Total Users 0 0 0 0 0 0 0 9 9

% of Census 0% 0% 0% 0% 0% 0% 0% 6% 1%Jun-19 Total Users 0 0 0 0 0 0 0 9 9

% of Census 0% 0% 0% 0% 0% 0% 0% 7% 1%

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Medication Measures

Beginning in September 2008 the OMHSAS Bureau of Community and Hospital Operations identified the following three medication measures for inclusion in this monthly report. The table information is compiled from the QS1 pharmacy software and reflects the unique count of the number of people served at each hospital on the last day of the month for each measure. Table 26 - Benzodiazepines

Measure Definition: Benzodiazepines refers to the number of unique patients served at each hospital, by level-of-care, who have an active, straight order for any benzodiazepine medication on the last day of each month.

Table 27 - Multiple Atypicals Measure Definition: Multiple Atypicals refers to the number of unique patients served at each hospital, by level-of-care, who have an active, straight order for two or more atypical antipsychotic medications on the last day of each month.

Table 28 - Typical-Atypical

Measure Definition: Typical-Atypicals refers to the number of unique patients served at each hospital, by level-of-care, who have an active, straight order for a typical and an atypical antipsychotic medication on the last day of each month.

BZD SRTP SysM/Y Cla Dan Nor Tor War Wer Total Nor Tor Cnt Tor TotalAug-18 93 73 61 59 86 76 448 21 11 32 10 490Nov-18 98 61 66 58 81 76 440 19 6 25 10 475Feb-19 99 69 67 56 80 79 450 16 11 27 9 486Jun-19 92 75 68 49 75 80 439 13 12 25 8 472

Forensic

Multiple Atypicals SRTP SysM/Y Cla Dan Nor Tor War Wer Total Nor Tor Cnt Tor Total

Aug-18 8 33 4 52 45 51 193 10 11 21 0 214Nov-18 7 37 6 58 44 46 198 14 7 21 0 219Feb-19 5 46 4 49 52 52 208 16 10 26 0 234Jun-19 18 38 4 42 47 51 200 16 19 35 0 235

Forensic

Typical - Atypical SRTP SysM/Y Cla Dan Nor Tor War Wer Total Nor Tor Cnt Tor Total

Aug-18 19 67 57 56 26 119 344 61 25 86 0 430Nov-18 18 63 39 48 29 126 323 61 27 88 0 411Feb-19 20 60 57 52 32 121 342 66 24 90 0 432Jun-19 37 46 48 55 38 124 348 58 41 99 0 447

Forensic

19

Table 29 - STAT Medication Usage – Civil Measure Definition: STAT medication are counted as psychiatric medications that have been administered. If two STAT medications are administered, it is counted as one event. Each STAT medication event is documented by “Route of Administration” and “Requested by”. This measure includes all levels of care.

Month Total Number

of STATs

PO IMPEG Tube:

Indv MD/DO RN

Jun-19 59 40 19 0 15 39 5

CLARKS SUMMIT (FY 2018-19)

Route of Admin Requested by:

Month Total Number

of STATs

PO IM Peg Tube: Indv MD/OD RN

Jun-19 168 40 128 0 29 1 138

DANVILLE (FY 2018-19)

Route of Admin Requested by:

Month Total Number

of STATs

PO IM Peg Tube: Indv MD/DO RN

Jun-19 112 33 79 15 17 80

NORRISTOWN - CIVIL (FY 2018-19)

Route of Admin Requested by:

Month Total Number

of STATs

PO IM Peg Tube: Indv MD/DO RN

Jun-19 142 49 93 0 26 25 91

TORRANCE - CIVIL (FY 2018-19)

Route of Admin Requested by:

Month Total Number

of STATs

PO IM Peg Tube Indv MD/DO RN

Jun-19 89 46 39 4 21 15 53

WARREN (FY 2018-19)

Route of Admin Requested by:

Month Total Number

of STATs

PO IM Peg Tube: Indv MD/DO RN

Jun-19 93 74 19 0 39 31 23

WERNERSVILLE (FY 2018-19)

Route of Admin Requested by:

20

Table 30 - STAT Medication Usage – Forensic

Month Total Number

of STATs

PO IM Peg Tube: Indv MD/DO RN

Jun-19 381 126 255 105 139 137

NORRISTOWN - FORENSIC (FY 2018-19)

Route of Admin Requested by:

Month Total Number

of STATs

PO IM Peg Tube: Indv MD/DO RN

Jun-19 111 60 51 0 38 37 36

TORRANCE - FORENSIC (FY 2018-19)

Route of Admin Requested by:

Table 31 - STAT Medication Usage – ACT 21 (SRTP)

Month Total Number

of STATs

PO IM Peg Tube: Indv MD/DO RN

Jun-19 14 13 1 0 7 5 2

TORRANCE - ACT 21 (FY 2018-19)

Route of Admin Requested by: